For example, the survey of hospitals including both participants and those denied participation-showed that 46 percent had some deficiency and that 89 percent of the extended care facilities needed to improve their operations to meet medicare's quality goals.

With this information in hand, we developed a program of consultation and training for State health departments to assist them in their facility certification process and to equip them with sufficient technical and program know-how so they can, in turn, assist the operators of facilities in their efforts to achieve the standards.

For the elderly patient and his family, these standards and our efforts to improve them mean a growing confidence in the quality of care purchased.

MAJOR ISSUES ON CARE

Beyond questions of quality lie the major issues of whether care is available, can older people afford the care, and will they use the services they need?

Central to these issues is the adequacy of our medical manpower supply. There are, as this committee knows, serious shortages in all the medical specialties. Perhaps the most significant for the elderly is the nursing shortage, where we estimate a current deficit of 125,000 nurses just to fill existing vacancies.

With the Office of Education, the Vocational Rehabilitation Administration, the Department of Labor, and with the assistance of such legislation as the Allied Health Professions Act adopted by the Congress last year, we hope to gain somewhat in the race to match medical manpower supply with the demands.

Last year, more than 35,000 nurses were graduated. More than 24,000 nurses came out of post high school programs. And approximately 20,000 hospital aides, orderlies, and attendants received entering training.

We have begun to develop another important resource in the nursing field by attempting to bring back into nursing a portion of the 300,000 licensed professional nurses in this country who are not practicing nursing.

Through contracts with States, we are supporting efforts to recruit these nurses, find employment for them, and through cooperation with the Manpower Development and Training Act, offer refresher courses. Our goal is to increase the number of nurses returning to active practice by 30,000 in the coming fiscal year.

Senator SMATHERS. Doctor, let me ask you a couple of questions right there. Has there been a decline in the hospital school of nursing? Dr. WAGNER. No, sir.

Senator SMATHERS. There has not been a decline?

Dr. WEISS. There has been a slight decline this year.

Senator SMATHERS. A rather substantial decline according to information on this side of the table.

Dr. WEISS. In terms of total number of schools there has been a substantial number.

Senator SMATHERS. Can we have you identified for the record.
Dr. WEISS. I am sorry.

My name is Dr. Jeffrey Weiss and I am an economist employed by the office for the Assistant Secretary for Program Coordination.

The total number of diploma schools has declined considerably in recent years but total output has not, that is number of graduates. However, this year, for the first time that is this fall of this academic year-there was a perceptible decline in the number of first-year entering students, a decline of about 8, 9, 10 percent, something in that

range.

VACANCIES IN NURSING SCHOOLS

Senator SMATHERS. Our information is that there are 4,000 vacancies in these schools and many hospitals that had previously been running nursing schools are now closing them because there is nobody coming to school.

Dr. WEISS. That information I would say is a general trend; it is substantially correct.

Senator SMATHERS. Why is that?

Dr. SILVER. There has been an increase in places in the associate degree programs; that is, the junior college programs, and in the baccalaureate programs. The total number of nurses graduating is not declining. The decline is wholly in the area of the diploma school graduates. You see, the diploma schools have very special problems. Senator SMATHERS. Like what?

Dr. SILVER. I think young people want a college degree or they want training that will compare with college training. The people who would be teaching nurses want to be associated with teaching institutions so that hospital schools have problems in recruiting faculty and in recruiting students.

The vacancies that you describe in diploma schools are there and the fact is that hospitals are closing their schools because they cannot recruit faculty or students.

Senator SMATHERS. Is it a fair generalization to say that it is a little better status symbol to be able to say that you have graduated from a

Dr. SILVER. You have a college degree.

Senator SMATHERS. That is right, rather than having graduated from the hospital nursing school where you get a certificate, but it does not look good on the wall.

Dr. SILVER. Yes. You can go 2 years to an associate degree school and become an RN or you can go 4 years and get a college degree so that it sort of preempts the 3-year schools.

Senator SMATHERS. But you can state, as the good doctor over here stated, that there is an increase in those young ladies and men who are studying to be nurses and we can expect a greater increase in nurses? Dr. SILVER. This past fall the largest number of student nurses ever entered into nurses training, about 48,000 or 49,000 students entered into training this past fall.

Senator SMATHERS. Now, even with the fact that you are increasing the number of students who are attending courses calculated to lead to a nursing degree, would you not agree that in the light of the enormous shortage of 120,000 nurses that we somehow should try to get more of the girls and boys to go to the hospital nursing schools, too?

Dr. SILVER. Senator, we are not trying to keep nurses out of training. We are trying to do everything possible to get them into training. I

think that one of the points that Dr. Wagner made, for example, was that by means of the nurse refresher program, which is a combined operation between the Public Health Service and Department of Labor and the Office of Education, we are trying to bring back 30,000 nurses this year, inactive-but licensed nurses-which would be the equivalent of 1 whole year's graduating class.

If the Congress would give us the ceiling of the opportunity grants that were voted in the legislation last year-no money was provided, only an authority that with those opportunity grants we might provide stipends for students which might encourage more students to go into nursing. We have the authority but we didn't get the appropriation.

Senator SMATHERS. How much of the authority was allowed you? Dr. SILVER. $5 million is the ceiling.

Senator SMATHERS. Passed both Houses?

Dr. SILVER. The authority, yes.
Senator SMATHERS. All right, sir.

You go ahead, Doctor.

Let me ask you one other question. I notice you talk an awful lot about nurses here. Do you get anybody to talk about the shortage of doctors?

Dr. SILVER. What should we talk about?

Senator SMATHERS. Well, I notice the American Medical Association stated yesterday, was it not, that they were alarmed by the fact that there is now a considerable shortage of doctors and they recognized it.

SHORTAGE OF PHYSICIANS

Dr. SILVER. I think that there is and has been for some time a significant shortage in physicians which is ascribable to a number of factors only part of which has been the very slow increase in the total number graduated. The shortage is much more acute in some parts of the country. For example, there are almost twice as many physicians per 100,000 population in the Northeast as there are in the Southeast. Some of the conditions of life and conditions of professional life are less attractive in some areas than in others.

Most of the students now graduating from medical school go into specialty training so that the differential shortage is more in the areas of family practice and pediatrics than it is in some of the specialties. We have to do many things to overcome the shortage and I would not consider simply producing more physicians as the essential answer. What we need to do is use the physicians more effectively to increase the productivity of doctors and to multiply their activity by providing physician assistants.

Now you mentioned, of course, sir, that more doctors are beginning to cluster together in groups which increases their efficiency and productivity. We think that this is something to be encouraged very strongly. We know that if you increase the productivity of the physicians in this country by only 5 percent it would be the equivalent of two graduating classes. This is one of the many things that we want to talk about at this conference next week; what things we are going to do to provide incentives and stimulus for more physicians to go into group practice.

We can multiply their efficiency, we can do far more than by simply working over a long period of time to turn out more doctors. It takes about 12 years from the time you start to plan a medical school until you have the product, the physician who can work with patients. We would like to do something more quickly than that.

PHYSICIANS' ASSISTANT

Senator SMATHERS. I don't want to delay this hearing but we have a lot of witnesses and a lot of ground to cover and I am talking too much. I am going to stop in a minute.

You said to develop a physician assistant.

Dr. SILVER. Yes.

Senator SMATHERS. What do you mean by that?

Dr. SILVER. Well, I have in mind a person who would be specially trained to work with the physician to do many of the things that require professional training that a physician is not required to perform. I have in mind, for example, the kind of study that was made among pediatricians in the State of Washington where it was shown that 50 percent of what the doctor was doing in his office need not be performed by someone with that much training. The business of taking the history and keeping records and handling telephone conversations in pediatrics, for example, rearranging the formula, consulting with the mother about guidance with respect to the growth and development of the child, many of these things would be carried on by people who don't need the advance training of 8 or 10 years of professional training that a physician has.

Senator SMATHERS. You know I happen to agree with you very strongly.

Dr. SILVER. Good.

Senator SMATHERS. I know the doctors don't like it but I was in the U.S. Marines for 4 years and I so well remember overseas where we had a sick call in the morning and you would see the fellows lined up to receive treatment for poison ivy, cuts, diarrhea, things of a minor nature, whatever it was. Then we had a couple of corpsmen there. The corpsmen had enough training and enough sense to know if a fellow came in there with a fever that he would set him aside and say "You have to see the head man; you have to see the doctor.' The doctors didn't mind this. Mind you, these were not Regular Navy doctors, this was World War II when these were private practitioners who, like everybody else, were going into service. It was a pretty good idea.

I have seen some of them since and say "Why don't you still have this same idea?" But they reply, "Oh, no, now we have to see everybody ourselves."

Well, anyway, this whole program, it seemed to me, took care of cuts, minor things of that nature, with fairly well-trained corpsmen who had some training, and was perfectly agreeable as far as the armed services were concerned. Four million people in service and nobody objected to it and it worked very well. You saved the doctors to do the very important and necessary things which they had to do and which only a doctor should do.

I never have understood why we cannot develop a system similar to that. I never heard it called a physician assistant before, but I like the idea. I don't know why we don't have a 2-year medical school for medical assistants.

Dr. SILVER. Dr. Wagner, himself, is involved in a program to develop specially trained assistants to work with purser's mates in the merchant marine.

Senator SMATHERS. We do this in all the services and it works well. I never have understood.

I understand there is a representative of the American Medical Association sitting out here this morning. I like doctors. I am for them. I think they render an enormous service and they should be respected. I know of no economic or political group in our society, next to the preachers, which gives more charity and gets more abuse for it. In this area I don't understand why they are not willing to go forward with a program of this particular nature, physician's assistants.

Dr. SILVER. The climate has changed, Senator. The doctors are not opposing. As a matter of fact, we have had expressions of cooperation from all kinds of physician groups to help us develop this. We now have on the agenda, for example, through the Health Services Research Center that we hope to establish in the Public Health Service and with which Dr. Wagner will be very intimately associated, to do some of the exploration and from the partnership for health bill hearings now in the Interstate and Foreign Commerce Committee. We need support for the programs that will help us accomplish this thing.

We know that it is necessary. We want to do it. We have the program ready to go and if we get the necessary appropriations and support from the Congress we will do it.

Mr. MILLER. I know from my own personal knowledge that the Michigan State Medical Society was promoting this idea at least 20 years ago. I am sure other medical societies have done so too. However, is not a basic factor in this the attitude of the patient himself? Isn't this an area that would require considerable educational effort to get a ready acceptance from the patient?

Senator SMATHERS. I think you are right. That is what some of the doctors have told me, that the patient's attitude is the critical factor. I think the reason is that the patient at that point has never talked with one of these qualified assistants. As patients see it, everybody's ailment is the worst. It does not matter what it is. They want the best. But once you get adjusted to talking to the physician's assistant, in some respects you might get a better, at least a longer treatment or a more thorough treatment from that physician's assistant.

I think it is a matter of educating the patients and public as well as the doctors. Every time I read of a doctor shortage I think, why don't we do this?

You call a doctor today, and I have an illustration right in my own office where we were trying to get a young lady in to see a certain specialist. She has to wait 3 weeks. She needs a doctor now. Now we can take her out and act like she is runover or something, maybe get some emergency treatment for her, but otherwise she has to wait 3 weeks.

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